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Provider Manual

Coding Quick Reference

Last Updated on August 28, 2018

Medicaid FFS Security Health Plan BadgerCare Plus Claim Coding
1. Multiple surgery 100 percent/50/25/13 (sequencing of claims) Modifier 51
100 percent/50/50/50,etc.
2. E & M New Patient A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Follow MA guidelines.
3. Bi-laterals 1 code, 50 modifier at 150% Follow MA guidelines.
4. Unusual service 22 modifier Not recognized Follow MA guidelines.
5. Prolonged services and critical care Only pay for 4 hours per date of service-manual review Manual review. Need physician notes.
6. Physician assistant (non-HPSA) 90% payment, bill under PA's number. Follow MA guidelines.
7. Physician assistant (HPSA) Payment the same as physician. Follow MA guidelines.
8. Surgical assist Physician - 20% of the surgical fee type of service 8
Physician assistant - 80% of the 20%
Follow MA guidelines.
Type of service not required. 
9. Obstetric (OB) services Use either the separate OB component procedure codes as they are performed or the appropriate global OB procedure code with the date of delivery as the date of service Follow MA guidelines. Notify Security Health Plan by letter of first date of visit or use MA codes for a no charge. Use the global code for complete care.
10. TMJ and splints Paid per maximum allowable fee schedules. Follow MA guidelines.
11. E & M on the same day as a procedure by the same provider Deny E & M Deny E & M unless a 25 modifier
12. Anesthesiologists Bill modifier with anesthesia codes. Use modifiers when supervising. Follow MA guidelines.
13. CRNA's CRNA's will bill under their own number or name with an appropriate modifier. Use anesthesia CPT codes. Follow MA guidelines.
14. DME rental purchase DME is rented but the day.
 
TOS - R (rental) 
P (purchased) 
DME rented by the month or day.
Modifier - RR (rental)
Modifer - NU (new/purchased) 
15. Professional component Modifier 26  Follow MA guidelines.
16. Technical component Modifier TC  Follow MA guidelines
17. Global X-ray* No modifier  Follow MA guidelines
18. Pre- and post-operative Varying number of days. Medicare guidelines.
19. Incidental surgery procedure Minor procedures.
Bundled in the major surgery. 
Bundled/unbundled edits according to CMS guidelines.
20. Second opinions Not required. Not required.
21. Hysterectomy consent Send to Security Health Plan.
Waived if patient is postmenopausal or sterile.
Send to Security Health Plan. Follow MA guidelines.
22. Norplant (insertion and supply) Combined code and supply Separate codes for insertion and supply.
23. Progesterone, estrogen, and estrone injections diagnostic ranges 4 per recipient per any 365-day period. Follow MA guidelines.
24. Weight management services Prioor authorization required after 5 visits; supplement is not covered. Follow MA guidelines.
25. Annual physical One comprehensive visit per adult per calendar year per physician. Follow MA guidelines.
26. Infusion pump No prior authorization required for the first 60 days. Per day reimbursement. Follow MA guidelines.
27. Ophthalmologist optometrist Fee schedule will be identified by provider type.  

*The technical component with a hospital inpatient place code is part of the hospital DRG and will not be paid separately by the HMO.